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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name(DBA);4a <br /> Address for Vehicle: p(( ©jf ' Sdo S <br /> Street Addressr j City <br /> 1) License Plate#: N _e79-1 4} Year. c <br /> 2) Vehicle Vin V. '7 <br /> ' �/6' &�1/ 5) Make/Modei: Jd <br /> 3) State Decal#. C 6) Color: 'yt�11� � <br /> VEHICLE OWNER:INFO MATION <br /> Name: <br /> Address of Owner: C-IF S '010 0 <br /> Street Address city <br /> The mobile food facility shall operate out of a commissary,and shall report to the commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office ay result in permit revocation and penalties. <br /> 442) <br /> nature of Vehicle <br /> Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: .. <br /> Owner Name: �,�. 2 ` kr ae±k C. <br /> Site Address: 71a I <br /> street address city <br /> Phone: (ZN) Ijits <br /> I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> IGl <br /> ?, Liquid&solid waste disposal Utensil washing sink <br /> (Z m3 eomparlmeMa) r ❑Store frozen food l4i Vehicle wash faalbes <br /> ❑Preparation of food Hot&cold water for cleaning ®Toilet&hand washing Store reingerated food <br /> ❑ <br /> toredry food/suppli ®Provide potable water Ovemight paddng Adequate electrical outlets <br /> Si nature of Co misse Owner/ er itor C421!- Date <br /> HEALTH DEPARTMENT ^ <br /> If the commissarylfood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissaryffood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/182008 <br />